REV-467 LE+ (02-14)
                                       AUTHORIZATION
                                       FOR RELEASE OF
      BUREAU OF ADMINISTRATIVE SERVICES
      DIRECTOR’S OFFICE                  TAX RECORDS
      12TH FL STRAWBERRY SQ
      HARRISBURG PA 17128-1200                                    PLEASE PRINT OR TYPE
  Pennsylvania tax records are confidential and may be released only to the taxpayer or pursuant to a release
  signed by the taxpayer. Unauthorized disclosure of tax information is a criminal offense.
  Completion of this form authorizes the PA Department of Revenue to release the tax return documents identified
  in Part ll.
  Carefully read the instructions on the reverse and fill out the form completely.

START PART I - DESIGNATION OF INDIVIDUAL TO RECEIVE TAX RECORDS
Ü 1.
      Full Name of Designated Individual                                              Telephone No.
  2.
      Name of Individual, Firm or Agency
  3.
      Street Address
  4.
      City                                              State          ZIP Code

  PART ll - TAX RECORDS TO BE RELEASED (See Instructions on reverse side.)
                 1                     2 3              4             5
      Taxpayer’s Name as
      Shown on Original ReturnTax ID No. Tax            Record    Tax Period

  6.
      Current Street Address of Taxpayer

      City                                 State                  ZIP Code
  7.
      Street Address Used in Filing Returns

      City                                 State                  ZIP Code
  PART III - CERTIFICATION
  I certify that l:
      am the individual whose tax records are to be released.
      am a duly authorized corporate officer of the corporation for which tax records are to be released.
                                       (Corporate Title)
      am a general partner of the partnership for which tax records are to be released.
      am empowered by a power of attorney on tax matters to request release of the tax records.
      (See instructions on reverse side.)
      have been appointed as the executor or administrator of the will or estate of the deceased taxpayer 
      whose tax records are to be released. (See instructions on reverse side.)
           PLEASE SIGN AFTER PRINTING
                        Signature                                 DateMM/DD/YY

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                               INSTRUCTIONS

PART I
Your designation identifies to the PA Department of Revenue the person, firm or agency to
whom/which the PA Department of Revenue should send the tax records you authorize for release.

Lines 1-4- If you authorize the release of your tax records to an agency or firm (such as a
government agency, scholarship board or mortgage lender) on line 2, you must include the name of
an individual we may contact and a daytime telephone number. Complete all address information on
lines 3 and 4.

PART II
Item 1.- If you authorize the release of a joint personal income tax return, indicate the names of
both spouses as shown on the original return.

Item 2.- For personal income tax records, enter your Social Security number. For joint tax records,
also enter your spouse’s Social Security number. Please include this information to expedite
processing your request.
If corporate tax records are requested, enter the Revenue ID or corporation tax account (box) number.
If sales tax records are requested, enter the sales tax license number.

Item 3.- Specify the kind of tax records to be released using the following abbreviations: personal
income tax (PIT), corporation tax (CT), sales and use tax (S&U), employer withholding (EMP).

Item 4.- Enter the record requested, for example, tax return, report or schedule.

Item 5.- Enter the year(s) of the tax records you are requesting. For fiscal year filers, enter the
period ending date. If you request more than five different periods, use additional forms. Returns filed
five or more years ago may not be available for release.

Item 6.- Enter your current street address.

Item 7.- If same as in Item 6, enter “Same.”

PART III
The PA Department of Revenue will accept only an original dated release signed by the taxpayer
identifying the specific tax records and tax years.
If you are not the taxpayer described in Part II, you must submit to the department a copy of your
authorization to request the release of the tax records. This usually will be a power of attorney on
tax matters or, if the taxpayer is deceased, sufficient evidence to establish that you are authorized to
act for the taxpayer’s estate.
Copies of joint returns may be furnished at the request of either the husband or the wife. Only one
signature is required.
Corporate tax records are available for release only by a duly authorized officer.
Partnership tax records are available for release only by a general partner.

WHERE TO FILE—Send the completed form to:
PA DEPARTMENT OF REVENUE
DIRECTOR’S OFFICE
BUREAU OF ADMINISTRATIVE SERVICES
12TH FL STRAWBERRY SQ
HARRISBURG PA 17128-1200

Please allow four to six weeks for your request to be processed.

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